CENTRAL GOVERNMENT HEALTH SCHEME Vs. R.N.MANICKAM

JUDGEMENT

(1.) The Opposite party in COP No.225/2005 on the file of the District Consumer Disputes Redressal Forum, Chennai (South) is the appellant herein. The case of the complainant was as follows :- As a retired IPS officer, he was covered by the provisions of the Central Government Health Scheme. At the relevant time he was suffering from severe bouts of cough and also giddiness and unsteadiness for over a period of time and even after treatment for the said ailment by three eminent doctors viz., Dr.Jagannathan, Dr.Ramdas and Dr.R.B.Singh of Apollo Hospitals, his condition did not show any improvement and on 23/8/2004 his health condition deteriorated and took a turn for the worse. Dr.Ramdas opined that the complainant required immediate medical attention and he suggested emergency admission and care in a major hospital having advanced facilities for major tests and emergency treatment. The complainant got admitted on 23/8/2004 on an emergent basis for investigation and treatment of his ailment, at Apollo Hospitals. X-ray revealed bilateral maxilliary sinusitis. He was retained for investigation and treatment till 30/8/2004 and then was discharged. Dr.Ramdas, Consultant ENT surgeon was consulted for pharyngitis and sinusitis. In view of the highly congested pharynx, he advised to rule out GERD. Nuclear scan of oesophagus and stomach revealed oesophageal motility disorder in supine position. He was started on proton pump inhibitors and mosapride. He was put on nebulised bronchodilators initially and inhaled bronchodilators later. In spite of medications his symptoms were decreasing very slowly than expected and an HRCT scan of the chest was done to rule out any abnormality of the lungs. The scan revealed no abnormality. Dr.Jagannathan reviewed him for longstanding parkinsonism, peripheral neuropathy and persistent unsteadiness. SPECT brain profusion scan was done and VBI insufficiency and gross abnormalities were ruled out. At the time of discharge, his throat congestion had decreased significantly but not completely. After discharge, he preferred a claim for Rs.48,773/- to the CGHS for medical reimbursement of amount spent on the treatment. All documents were enclosed. On 21/12/2004 the opposite party sent a communication rejecting the claim on the ground that there was no emergency grounds / life threatening conditions involved at the time of admission and therefore the claim could not be considered for reimbursement. The complainant subsequently produced a certificate from the doctor who treated him at Apollo Hospitals stating that he was indeed admitted under emergency conditions for treatment. However, the opposite party was still unwilling to settle the claim. The basis on which such a decision was reached was not given in the communication from the opposite party ; who was involved in arriving at the decision. The rejection of the complainants legitimate and valid claim is a gross deficiency in service arising out of negligence. No valid reasons or grounds had been given which amounted to clear deficiency in service on the part of the opposite party. Because of the refusal of the opposite party to settle the claim, the complainant was forced to settle the sum of Rs.48,773/- from and out of his own funds. Besides paying the amount spent , the complainant was entitled to compensation restricted to Rs.25,000/-.

(2.) The version of the opposite party was to the following effect :- The Central Government Health Scheme [CGHS] was a service organisation rendering free service to the beneficiaries and the CGHS contribution was collected only towards enrolment of the beneficiaries and not for treatment. The complainant could not therefore be stated to be a consumer nor the opposite party could be stated to be a service provider. The Consumer Forum had no jurisdiction to entertain the complaint. The claim of the complainant was scrutinised by the office of the opposite party. It was found that the emergency certificate from the treating doctor indicating the emergent nature of illness was not enclosed with the claim and only thereafter the certificate was produced stating that the complainant was admitted on an emergency basis. After receipt of the said certificate, the claim papers were again scrutinised by the opposite party. It was found that the treatment of severe bouts of cough did not indicate any emergency condition of the patient at the time of admission. The patient could have gone through CGHS dispensary for treatment of his ailment. The procedure for which the complainant obtained treatment from Apollo Hospitals was not in the list of specialities for which Apollo Hospitals was recognised under CGHS. Since the complainant was a pensioner, the recognised private hospital would have given him credit facilities and the bills would have been sent to CGHS, Chennai for obtaining payment. The Additional Director of the opposite party, a qualified medical person, concluded that there was no life threatening emergency and rejected the reimbursement claim. The treatment availed by the complainant at Apollo Hospitals was his choice treatment. He had himself stated in his forwarding letter dated 29/9/2004 that he had been consulting doctors at Apollo Hospitals for some time for treatment of violent cough, giddiness and unstable walk. For treatment of such problems, Apollo Hospitals was not recognised under CGHS and the claim made by the complainant was not legitimate. The complaint was liable to be dismissed.

(3.) Before the District Forum, on the side of the complainant, Exs.A-1 to A-34 were marked while on the side of the opposite party Exs.B-1 and B-2 were marked.